DOWNLOADS
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For Patients Patient History Form (Female) - 3 pages. This is our basic patient medical history form which needs to be filled out before your initial consultation. Patient History Form (Male) - 3 pages. This is our basic patient medical history form which needs to be filled out before your initial consultation. Patient Demographic Form - 1 page. This authorization form gives us permission to obtain the necessary medical files which may be helpful in your diagnosis. IUI Consent Form - 1 page. This authorization form is needed for an Intrauterine Insemination procedure. IVF Consent Form - 5pages. This consent form contains important concerning In Vitro Fertilization procedures. FET Consent Form - 1 page. This authorization form pertains to the thaw and tranfer of frozen embryos. HIPAA Patient Consent Form - 2 pages. This authorization form pertains to use and disclosure of health information for treatment, payment or healthcare operations.
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For Donors Donor Letter - 1 page. Our cover letter welcoming you to the Donor Program. Egg Donor Information Booklet - 6 pages. A description of the processes and procedures necessary in order to donate eggs. Instructions for Oocyte Donor Personal History Three Part Questionnaire - 1 page on how to properly fill out the Three Part Questionnaire. Donor Profile - Personal History (Part 1) - 3 pages Donor Profile - Philosophy About Donating Eggs (Part 2) - 6 pages Donor Profile - Medical (Part 3) - 9 pages Donor Demographic Form - 1 page. This form contains identifying information for our records. It remains confidential. HIPAA Consent Form - 2 pages
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For Recipients HIPAA Consent Form - 2 pages. This authorization form pertains to use and disclosure of health information for treatment, payment or healthcare operations. Male History - 3 pages. This is our basic patient medical history form which needs to be filled out before your initial consultation. Female History - 3 pages. This is our basic patient medical history form which needs to be filled out before your initial consultation. Demographic Sheet - 1 page. This authorization form gives us permission to obtain the necessary medical files which may be helpful in your diagnosis. Recipient Profile for Donor Selection - 1 page. This will help us understand the characteristics you are looking for in a donor Recipient Consent to Review Photos – 1 page. This consent will give you permission to view photos of donors.
Syracuse Information Syracuse Contact Information - 1 page. This is a list of Oocyte Donor Coordinators located in our Syracuse Office. Syracuse Recipient Check List - 1 page. This is a list of all paperwork that needs to be forwarded to the Syracuse Office prior to your initial consultation. Albany Information Albany Contact Information - 1 page. This is a list of Oocyte Donor Coordinators located in our Albany Office.
Albany Recipient Check List - 1 page. This is a list of all paperwork that needs to be forwarded to the Albany Office prior to your initial consultation. |
General Forms HIPAA Privacy Notice - 6 pages. This document describes how information about you can be used and disclosed and how you can get access to this information. Typical IVF Calendar - 1 page. This sheet represents a typical IVF timeline based on a 28-day menstrual cycle. Actual dates of medication injections, ultrasounds, blood tests, egg retrieval, embryo transfer and such will vary from patient to patient and is dependant upon many variables. This sheet is only a general reference, but it is helpful in knowing what you should expect.
(Updated 3/19/08 |
